PMID: Konda SR et al. hb```e``z Bl@hOOKe_ %fAG=&=t348[9KwjIa|,oQZK]btA]}~ Traumatic Arthrotomy (forums.mtbr.com) Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment. (Publisher Information)Tj 150 cc saline load into joint has high negative predictive value and 95% sensitivity in detecting small joint injuries. -5.416 0 Td Please enable scripts and reload this page. 0000001570 00000 n PMID: 22215059, Your email address will not be published. Gun shot wounds (GSWs) are high energy injuries that contribute to extensive soft tissue damage and comminuted bony fractures. Keblish15 has developed and re-ported on the use of a lateral reti-nacular approach for the valgus knee. After confirmation of placement, begin slowly injecting saline into joint capsule. Evaluation of saline load test for simulated traumatic arthrotomies of the ankle. <>stream The workhorse open surgical approach to the knee is the medial parapatellar approach; however, arthroscopic irrigation and debridement (I&D) should be considered in the setting of small puncture wounds (e.g., gunshot wounds). ( and click on the [Reprints and)Tj 15 0 0 15 72 513.99997 Tm PMID: 25150328, Makhni MC. Results: Injury. -9.58399 0 Td Diagnosis can be made clinically with the inability to perform a straight leg raise and confirmed with radiographs of the knee. yj3wNUn%oNd{e]i A knee effusion may result from acute or chronic conditions. 0000071109 00000 n Brubacher, Jacob W. MD; Grote, Caleb W. MD, PhD; Tilley, Michael B. MD. Different training hospitals using our PASS training platform. located just lateral to peroneus tertius and superficial peroneal nerve and medial to lateral malleolus can trace out superficial peroneal nerve prior to incision Anterocentral function anterior viewing portal location and technique not commonly utilized due to danger to dorsal pedis artery medial to EDL and lateral to EHL Posterolateral function Causes range from acute trauma to chronic systemic disease. Methods: Forty-two patients undergoing elective ankle arthroscopy were prospectively enrolled. Exam is notable for a deep laceration slightly inferior and lateral to his left patella. J Orthop Traum 2012; 26: 3479. retrospectively reviewed the overall treatment costs associated with isolated low-energy GSWs to the extremity and the estimate cost savings associated with a single-dose IV antibiotic strategy administered in the emergency room for patients with simple GSWs. Initial evaluation of periarticular wounds includes thorough examination of the wound and plain radiographs. Much of the above literature reveals deficiencies of sensitivity for evaluation of traumatic arthrotomy. An arthrotomy is indicated in these cases. A positive study is clearly evident with either modality (eg SLT with extrusion of fluid, CT with free air in joint). /T1_1 1 Tf Irrigation and Debridement of Septic Hip - Approaches - Orthobullets. J Wrist Surg. S /T1_2 1 Tf The preponderance (53% to 91%) of traumatic ar-throtomies occur in the knee1-3, and such injuries occur more commonly in males2,4. The .gov means its official. Unique videos published in our learning community. (\240)Tj Other studies revealed a false negative rate of 67% with volumes up to 105 mL (saline + methylene blue) and 95 mL (saline alone) and sensitivities of only 36% at volumes of 60 mL. (jbjs.org)Tj Generally, primary closure of the wound is contraindicated. Required fields are marked *. ET Different countries in which training hospitals use our PASS Enterprise analytics platform. 0 1 TD <> ), skin is supplied by perforating arteries which run in the muscular fascia so any medial or lateral skin flaps (if needed) should be just below (deep to) the fascia to avoid. Answer 4: Local wound care, tetanus prophylaxis, and administration of IV antibiotics have been showed to be appropriate for low-velocity intra-articular GSWs. midvastus approach. Trauma 2013; 27: 498504. TECHNIQUE STEPS. Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. -8.971 0 Td 2021 Dec 29;13(12):e20793. They reported that the overall cost associated with isolated low-energy GSWs to the extremity is high. Definition: a deep laceration that extends into the joint capsule, exposing the intra-articular surface to the environment, History: Mechanisms that should raise suspicion for violation of the joint capsule include penetrating trauma (knives, sharp objects, gunshot), falls, or other high energy injuries, Traumatic Arthrotomy Workup Flow (epmonthly.com), Bariteau JT et al. Sterilize the skin of the lower extremity from distal quadriceps to proximal calf with betadine or chlorhexidine. 2020 Apr;51(4):1114-1117. doi: 10.1016/j.injury.2020.02.087. xref He reports falling onto his left knee, then sliding to a stop under a parked car, colliding with a grate on the street. al., 2009). Saline Load Test for Detecting Traumatic Arthrotomy in the Wrist. Confirm entry into the joint with aspiration of synovial fluid (assuming remaining synovial fluid after injury). More study is definitely needed to compare SLT to CT with a larger number of patients. government site. The site is secure. 99 0 obj PMID: of the saline load test in diagnosis of traumatic elbow arthrotomies. Your message has been successfully sent to your colleague. Understanding the anatomic landmarks and capsular extensions of the major joints is key to proper evaluation. Disclaimer. Ligaments, cartilages, and tendons are key structures both around and outside the joint. 0000000616 00000 n 101 0 obj Keese GR, Boody AR, Wongworawat MD, Jobe CM. A systematic review of the literature. The clinician uses a sterile technique to inject saline into the knee (or other joint space) using an 18g needle and syringe (Nord, et. -1.68549 -2.3 Td -3.028 0 Td Johns et al found arthroscopic treatment to be preferable to open treatment in both adult and pediatric patients with acute septic arthritis of the knee. That is to say, either study alone with a positive finding promptly concludes the diagnostic process, but either study alone with a negative finding leaves diagnostic uncertainty. vancomycin), If significant soft tissue injury, add gram negative coverage like late generation cephalosporin, extended-spectrum penicillin, or aminoglycoside (i.e. Diagnosis can be made with plain radiographs of the knee. Careers. -5.721 0 Td /T1_2 1 Tf An inferomedial injection location requires significantly less fluid than a superomedial injection location does for the diagnosis of inferolateral arthrotomies of the knee. Hip Direct Lateral Approach (Hardinge, Transgluteal) Hip Posterior Approach (Moore or Southern) Thoracic Spine. 13.2 -2.00001 Td Aspirate as the needle is advanced. Open knee joint injuries--an evidence-based approach to management. PMID: 23490316. -72 -557 m Under sterile conditions, fill a 60mL syringe with sterile normal saline (+/- 1-2 cc methylene blue). (20 Pickering Street, Needham, MA 02492-3157)Tj 2023 Lineage Medical, Inc. All rights reserved. 0000003779 00000 n Some error has occurred while processing your request. PMC For more information, please refer to our Privacy Policy. endobj <> HHS Vulnerability Disclosure, Help may extend to distal two thirds of femur; incise between rectus femoris and vastus medialis; split underlying vastus intermedius to expose femur; Variations . PMID: Your email address will not be published. <> 0000001148 00000 n There was no correlation between necessary injection volume and sex, body mass index, or knee circumference. Answer 5: Primary closure of the GSW is contraindicated. <>>> arthrotomy, the valgus deformity sufficiently facilitates general expo-sure so that access to the posterolat-eral corner of the knee joint is not difficult, even in patients with ex-treme obesity. In the absence of intra-articular pathology, intra-articular gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection and may be treated with local wound care, tetanus, and IV antibiotics. <> Are you sure you want to trigger topic in your Anconeus AI algorithm? While the procedure itself is relatively straightforward, there is debate in the orthopedic literature over how well it performs and what amount of fluid must be injected to truly rule out a small arthrotomy. /T1_1 1 Tf Please enable it to take advantage of the complete set of features! (Solution Load Test)Tj There are no studies that directly compare CT to saline loading in a randomized fashion and no studies that propose a definitive algorithm combining these two modalities to exclude knee joint injury. Journal of the American Academy of Orthopaedic Surgeons, Get new journal Tables of Contents sent right to your email inbox, Articles in PubMed by Jacob W. Brubacher, MD, Articles in Google Scholar by Jacob W. Brubacher, MD, Other articles in this journal by Jacob W. Brubacher, MD. Distal Femur Fracture ORIF with Single Lateral Plate. Knee & Sports Pediatrics Recon Hand Foot & Ankle Pathology Basic Science Anatomy TECHNIQUES Trauma Spine Shoulder & Elbow Knee & Sports Pediatrics Recon Hand Foot & Ankle Pathology Approaches FEATURES Cards QBank Cases Topics Evidence Posts Videos Events PEAK & Study Plans PASS Self-Assessment Exam POCL FREE CME Price Chart (www.jbjs.org)Tj [100 0 R 101 0 R 102 0 R] Epub 2020 Feb 19. eCollection 2021 Dec. Patel AH, Wilder JH, Lee OC, Ross AJ, Vemulapalli KC, Gladden PB, Martin MP 3rd, Sherman WF. Unique people that have viewed our content. In one series, a volume of 194 mL was required to achieve a 95% sensitivity for small injuries. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J Orthop Trauma. Effectiveness of the saline load test in diagnosis of simulated traumatic ankle arthrotomies. Bookshelf 0 g Hip Arthroscopy - Knee & Sports - Orthobullets Knee Evaluation in the Athlete Meniscal injuries Ligament injury Knee Overuse injuries Knee Extensor Mechanism Knee Cartilage Lesions Pediatric Knee Team physician Head & Neck Sports Injuries Updated: Mar 24 2023 Hip Arthroscopy } Matthew J. Steffes MD Experts 66 Bullets 198 Cards 21 Questions 9 Cases 0 1.00001 TD Diagnosis is made clinically by assessing the size and nature of the external wound as well as obtaining radiographs of the bone at the location of the soft tissue injury. METHODS: Fifty-six consecutive patients scheduled for knee arthroscopy were enrolled. 0 1.00001 TD The Effectiveness of Saline Load Test in Detecting Simulated Traumatic Elbow Arthrotomies: A Cadaveric Investigation. 0 0 1 rg None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Brubacher, Dr. Grote, and Dr. Tilley. /T1_2 1 Tf 8 0 0 8 200.45184 578.99994 Tm The volume of injected fluid was recorded. -10.94501 0 Td /T1_1 1 Tf Physician votes on our clinical treatment polls. Traumatic Elbow Arthrotomy Pediatric Case Report: The Saline Load Test is a Reliable Method of Detection. Cards published by our editorial team or personal cards created by our users. Allegra PR, Sanchez RA, Huntley S, Latta L, Desai SS, Kaplan J, Aiyer A. RT/ Pg`/y, AAEb=*, " 98 0 obj Would you like email updates of new search results? Introduction Provides exposure to distal tibia ankle joint talar dome Indications include ORIF of pilon fractures ankle arthrodesis total ankle arthroplasty I&D of infected ankles removal of loose bodies Intermuscular plane Intermuscular plane extensor hallucis longus (deep peroneal nerve) extensor digitorum longus (deep peroneal nerve) Preparation Moreover, in the absence of IA pathology, IA gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. In order to detect 95% of 1-cm inferolateral arthrotomies of the knee with use of the saline solution load test, 155 mL must be injected. Keller Procedure (resection arthroplasty) indications elderly, low demand patients with significant joint degeneration and loss of motion that allows for rapid rehabilitation contraindications patients with pre-existing rigid hyperextension deformity of 1st MTP joint outcomes good results have been noted in low demand elderly patients Are you sure you want to trigger topic in your Anconeus AI algorithm? Please try again soon. /T1_1 1 Tf Please try after some time. ( 2009;91:66-70. TECHNIQUE STEPS. Q endobj 0000001672 00000 n Epub 2019 Mar 8. /T1_2 1 Tf [ 38, 39] Arthrotomy is the best. the tibia is the most common site of post-surgical osteomyelitis following surgical treatment of open fractures, delay in defintive soft tissue coverage greater than 7 days. One study found that CT scanning of the joint had superior performance to saline loading test in the detection of joint injury. There is little data in the literature about what constitutes a high-risk injury aside from deeply penetrating trauma such as gunshot and stab wounds. Damage to the synovial joint of one or more of the three . Q Setup, Positioning, and Joint access. muscle belly of the vastus medialis is lifted off the intermuscular septum. Orthobullets Team. patella can be difficult to evert and is subluxated laterally instead. 0000001875 00000 n Are you sure you want to trigger topic in your Anconeus AI algorithm? evaluation for traumatic arthrotomy of the knee Treatment Nonoperative urgent IV antibiotics, tetanus prophylaxis, and extremity stabilization and dressing indications initial treatment for all open fractures a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise Wolters Kluwer Health 105 0 obj zosyn), If seawater contamination and concern for vibrio vulnificus, add doxycycline, Functional impairment correlates to the severity of injury, Infection rate from periarticular wounds ranges from 0% to 11.8%, Improved outcomes if diagnosis and treatment is achieved within 24 hours of injury (, Always suspect an open joint if there is a laceration, regardless of size, the lies over joint, Use the Ssaline load test to assess for joint capsule injury. . 0 g 21.02501 1 Td Open Knee Joint Injuriesan evidence-based approach to management. Inject 2-4 mL lidocaine 1-2% (+/- epi) in a contralateral position to the injury, tracking along the planned aspiration pathway. Full article PDFs linked to scientific journals. ( )Tj Traditionally, the saline loading test (SLT) has been a staple of investigation for possible traumatic arthrotomy. Quite useful for orthopaedic residents, GPs and med students. The potential advantage of -72 -471 m Arthroscopy is a surgical technique that can be applied to perform the following types of procedures: Chondral defect repair, including microfracture, controversial whether or not it provides symptomatic relief, but makes figure-four position more difficult, Place tourniquet (important for safety, but often not inflated), Make anterolateral incision over soft spot of knee, have advantage of increased superior-inferior mobility of instruments, have advantage of increased medial-lateral mobility of instruments, advance blade into capsule then follow with trochar, make with knee in flexion, adjacent to patellar tendon over soft spot on joint line, used as the primary instrumentation portal, most common site for aspiration or injection, 1 cm above joint line between LCL and biceps tendon, 1 cm distal to patella and splits the patellar tendon, do not use if performing a bone-patella-bone graft harvest, used for anterior compartment visualization, place where can be best utilized for need, Should systematically check the following locations and structures, with knee flexed to 90 move to medial compartment, with knee in figure-four position finish in lateral compartment, Shoulder Anterior (Deltopectoral) Approach, Shoulder Lateral (Deltoid Splitting) Approach, Shoulder Arthroscopy: Indications & Approach, Anterior (Brachialis Splitting) Approach to Humerus, Posterior Approach to the Acetabulum (Kocher-Langenbeck), Extensile (extended iliofemoral) Approach to Acetabulum, Hip Anterolateral Approach (Watson-Jones), Hip Direct Lateral Approach (Hardinge, Transgluteal), Hip Posterior Approach (Moore or Southern), Anteromedial Approach to Medial Malleolus and Ankle, Posteromedial Approach to Medial Malleolus, Gatellier Posterolateral Approach to Ankle, Tarsus and Ankle Kocher (Lateral) Approach, Ollier's Lateral Approach to the Hindfoot, Medial approach to MTP joint of great toe, Dorsomedial Approach to MTP Joint of Great Toe, Posterior Approach to Thoracolumbar Spine, Retroperitoneal (Anterolateral) Approach to the Lumbar Spine. In the absence of intra-articular pathology, intra-articular gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. endobj Setup. Clipboard, Search History, and several other advanced features are temporarily unavailable. endstream A similar study found 95% sensitivity at a volume of 155 mL. Split Anterior Tibial Tendon Transfer. The knee joint capsule itself can be violated by soft tissue injuries near the joint; this constitutes a surgical emergency that usually will require urgent orthopedic consultation. Rarely life threatening: 14. 12.54452 1 Td Total comments made from experts in the field. Detection of a traumatic arthrotomy in the pediatric knee using the saline solution load test. to maintaining your privacy and will not share your personal information without gentamycin), If concern for fecal or clostridial infection, add high dose penicillin (i.e. 2023 Lineage Medical, Inc. All rights reserved. 0000071241 00000 n Hip Anterior Approach (Smith-Petersen) Hip Anterolateral Approach (Watson-Jones) Hip Medial Approach. anteroposterior and lateral), May be up to 100% sensitive for joint violation, Study limited by small numbers, inclusion bias + inadequate gold standard, Could potentially be used instead of or, more likely, in addition to the slide load test in the appropriate clinical setting, Standard tool for assessment of traumatic arthrotomy, Particularly useful if physical examination equivocal or plain radiographs non-diagnostic, Perform arthrocentesis of the joint with a large bore needle (18-20 gauge), Sterile saline is injected into the joint while passive movement is applied to the joint, The laceration site is watched for saline extravasation indicating communication between the joint and external environment, Sensitivity ranges from 34%-99% depending on the study, joint, and the amount of saline used to load the joint (, Aids in distinguishing a true positive from additional bleeding from the wound, Recent studies suggest that the addition of methylene blue does not increase sensitivity if a sufficient amount of saline is used (, Varies depending on the joint in which you are injecting, Higher volumes increase sensitivity but also increase pain for the patient, Irrigate grossly contaminated wounds in the ED, Immobilize the joint to prevent further injury, Obtain early orthopedic evaluation for joint exploration, and washout to be performed within 6-24 hours, Prophylactic antibiotics (best if given within 6 hours), generation cephalosporin (i.e. 2007 Aug;21(7):442-3. doi: 10.1097/BOT.0b013e31812e5186. I feel like inserting a needle and injecting into a joint space would track air into that space and then your CT would not be properly interpretable. Knee Arthroscopy - Approaches - Orthobullets Shoulder Approaches Humerus Approaches Elbow Approaches Forearm & Wrist Approaches Hand Approaches Acetabulum Approaches Hip Approaches Thoracic Spine Lumbar Spine Updated: Aug 2 2018 Knee Arthroscopy } David Abbasi MD Bullets 91 Questions 2 Cases 1 Evidence 5 Video/Pods 2 4.8 ( 16 ) 2 Topic Podcast A high index of suspicion must be maintained for this injury. For example, if laceration/injury inferomedial aspect of knee, inject at the superolateral aspect, tracking toward joint capsule. /T1_1 1 Tf Detection of traumatic arthrotomy of the knee using the saline solution load test In order to detect 95% of 1-cm inferolateral arthrotomies of the knee with use of the saline solution load test, 155 mL must be injected. 103 0 obj document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Note: this service is provided by a third party, we do not collect your information in any way. official website and that any information you provide is encrypted Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Plain radiographs are negative for fracture. Scientific journals integrated with our learning platform. 2020 Mar 2;5(1):2473011420905610. doi: 10.1177/2473011420905610. 18.921 -2.00001 Td proximal portion of the arthrotomy extends into the muscle belly of the vastus medialis. %PDF-1.6 % A systematic review of the literature. Are you sure you want to trigger topic in your Anconeus AI algorithm? As you assemble laceration repair supplies, you begin to consider the possibility of knee joint involvement. Conclusions: Browning BB, Ventimiglia AV, Dixit A, Illical E, Urban WP, Jauregui JJ. Number of times users have rated our content. Antibiotic use is somewhat controversial, however, low-velocity intra-articular (IA) GSWs may be effectively managed with antibiotics. Healthcare. Q Browning BB et al. Preoperative Patient Care. Some authors recommend gently ranging the joint to increase visualization of extrusion of fluid. Views on the site, app, or social media channels. While these injuries can occur at any J Orthop Trauma 2007; 21: 442443. Considering this information, the prudent EP may be left with a persistent question regarding traumatic arthrotomy and the safety of primary skin closure prior to definitive diagnostics. recognizing a penetrating injury (i.e., a traumatic arthrotomy) that contaminates the joint by making it contiguous with the skin. The https:// ensures that you are connecting to the CT scan of the joint may have even greater sensitivity for small volumes of intra-articular air. Does the saline load test still have a role in the orthopaedic world? J. Trauma 71 2011; E110113. Healthcare providers who have registered for our community. Treatment depends on location of fracture but generally requires immediate IV antibiotics and urgent irrigation and debridement followed by surgical fixation as needed. Diagnosis and Management of Partial Thickness Rotator Cuff Tears: A Technical Considerations and Fluoroscopy in Percutaneous Fixation of the Pelvis Biomechanics and Clinical Outcomes of Partial Meniscectomy, Privacy Policy (Updated December 15, 2022). eCollection 2022. The incidence of infection after IA gunshot injuries is low with the routine use of antibiotic prophylaxis. (The PDF of the article you requested follows this cover page. An official website of the United States government. `1AAGGKhh(t H$*(P( Tornetta and Collins 1 (1996) reported 25 patients in whom a partial medial parapatellar arthrotomy was performed with the knee in a semi-extended position (15-degree bend of the knee joint), with two-thirds of the the retinaculum split. Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. Acta Orthop Traumatol Turc 2016; 50: 597-600. Diagnosis of Traumatic Ankle Arthrotomies Using Saline Load Tests, Methylene Blue, and Radiopaque Tracer: A Cadaveric Study. Also known as "traumatic arthrotomy". Given the limitations of the saline loading test, are there additional diagnostic options? Sensitivity of the saline load test with and without methylene blue dye in the diagnosis of artificial traumatic knee arthrotomies. (This is an enhanced PDF from The Journal of Bone and Joint Surgery)Tj /T1_2 1 Tf (Detection of Traumatic Arthrotomy of the Knee Using the Saline)Tj Traumatic Arthrotomy. Feathers T et al. A laceration into the joint exposes the normally sterile intra-articular contents to external contamination. *A=`vttJx;vEYj;1 |H>$H!lllp"wAAGw^R. GO>G69#x=t4sq^Y\@+P(bt+G[lmmXFO+,,{.iFVN3e+WvbVu%KZ9%Hh0CCC7o=z&MtQFTN 8{^~ ===++kv=zRA~&rBi6lijj*F 4? The purpose of the present study was to determine the appropriate volume and needle location for the diagnosis of a traumatic knee arthrotomy and to assess the effect of associated variables, including knee circumference, body mass index, and sex. Foot Ankle Orthop. From the Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas. Answer 4: Local wound care, tetanus prophylaxis, and administration of IV antibiotics have been showed to be appropriate for low-velocity intra-articular GSWs. When one considers that a typical synovial fluid volume of the knee is around 7 mL [pmid 8779258], injecting 150 mL or more into that joint is a procedure that will require logistical planning and coaching of a cooperative patient. /RelativeColorimetric ri (J Bone Joint Surg Am. cefazolin or cefuroxime), If risk factors for MRSA present, use agent with activity against MRSA (i.e. Epub 2016 Dec 12. (\240 )Tj Ponseti Technique in the Treatment of Clubfoot. midvastus approach. 96 16 Indications Generally, total knee arthroplasty (TKA) is performed for destruction of joint cartilage either from osteoarthritis, rheumatoid arthritis/inflammatory arthritis, posttraumatic degenerative joint disease, or osteonecrosis/joint collapse with cartilage destruction. 0000071188 00000 n 2022 Jan 30;14(1):31909. doi: 10.52965/001c.31909. Ohio Health Orthopedic Trauma and Reconstructive Surgery. ( )Tj /T1_0 1 Tf 2021 Feb 01;35(2):e61-e63. /T1_1 1 Tf 0 g (order reprints or request permission)Tj document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); How To Confidently Rule Out Traumatic Arthrotomy of the Knee. (Russell M. Nord, Tony Quach, Michael Walsh, David Pereira and Nirmal C. \ Tejwani \240 )Tj TECHNIQUE VIDEO. J Ortho Trauma 2012]. Epidemiology. Ankle Arthritis is degenerative joint disease of the tibiotalar joint that can be broken into three main types: osteoarthritis, post-traumatic arthritis, and inflammatory arthritis. Current treatment of traumatic arthrotomy includes intravenous antibiotics and surgical irrigation and dbridement. PMID: Keese GR et al. <>stream <>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Type/Page>> They concluded that in the absence of IA pathology, IA gunshot injuries do not appear to necessitate surgical debridement to decrease the risk of infection. timing of flap coverage for open tibial fractures remains controversial, increased risk of infection beyond 7 days, increase by 16% for each day beyond day 7, early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study), can proceed with bone grafting after wound is clean and closed, negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days), open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology, Masquelet technique ("induced-membrane" technique), 1st stage: I&D, cement spacer and temporizing fixation, 2nd stage: placement of bone graft into "induced membrane" and definitive fixation, Studies show optimal time frame for bone grafting to be, fracture-related infection ranges from <1% in type I open fractures to 30% in type III fractures.